Provider Demographics
NPI:1679630008
Name:SOUTH MISSISSIPPI STATE HOSPITAL
Entity Type:Organization
Organization Name:SOUTH MISSISSIPPI STATE HOSPITAL
Other - Org Name:SOUTH MISSISSIPPI STATE HOSPITAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:HOSPITAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:CLINT
Authorized Official - Middle Name:
Authorized Official - Last Name:ASHLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-794-0152
Mailing Address - Street 1:823 HIGHWAY 589
Mailing Address - Street 2:
Mailing Address - City:PURVIS
Mailing Address - State:MS
Mailing Address - Zip Code:39475-4194
Mailing Address - Country:US
Mailing Address - Phone:601-794-0201
Mailing Address - Fax:601-794-0220
Practice Address - Street 1:823 HIGHWAY 589
Practice Address - Street 2:
Practice Address - City:PURVIS
Practice Address - State:MS
Practice Address - Zip Code:39475-4194
Practice Address - Country:US
Practice Address - Phone:601-794-0201
Practice Address - Fax:601-794-0220
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-03
Last Update Date:2016-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS04871/3.13336I0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336I0012XSuppliersPharmacyInstitutional Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2046299OtherPK